Challenges faced by the HIV testing system in low- and middle-income countries

Introduction Determining the HIV status of some individuals remains challenging due to multidimensional factors such as flaws in diagnostic systems, technological challenges, and viral diversity. This report pinpoints challenges faced by the HIV testing system in Cameroon. Case presentation A 53-year-old male received a positive HIV result by a rapid testing algorithm in July 2016. Not convinced of his HIV status, he requested additional tests. In February 2017, he received a positive result using ImmunoComb® II HIV 1 & 2 BiSpot and Roche cobas electrochemiluminescence assays. A sample sent to France in April 2017 was positive on the Bio-Rad GenScreen™ HIV 1/2, but serotyping was indeterminate, and viral load was < 20 copies/mL. The Roche electrochemiluminescence immunoassay and INNO-LIA HIV I/II Score were negative for samples collected in 2018. A sample collected in July 2019 and tested with VIDAS® HIV Duo Ultra enzyme-linked fluorescent assay and Geenius™ HIV 1/2 Confirmatory Assay was positive, but negative with Western blot; CD4 count was 1380 cells/mm3 and HIV proviral DNA tested in France was ‘target-not-detected’. Some rapid tests were still positive in 2020 and 2021. Serotyping remained indeterminate, and viral load was ‘target-not-detected’. There were no self-reported exposure to HIV risk factors, and his wife was HIV-seronegative. Management and outcome Given that the patient remained asymptomatic with no evidence of viral replication, no antiretroviral therapy was initiated. Conclusion This case highlights the struggles faced by some individuals in confirming their HIV status and the need to update existing technologies and develop an algorithm for managing exceptional cases.


Background
HIV-1 infection is still a significant public health concern in sub-Saharan Africa, where over twothirds of the world's burden is found. Nevertheless, the number of new infections has dropped from about 1 950 000 in 2000 to approximately 870 000 in 2020. 1 Following this remarkable achievement, the Joint United Nations Programme on HIV/AIDS 2025 goals of 95-95-95 and eradicating HIV/AIDS by 2030 are now feasible targets. 2 Efforts in early diagnosis and the scaleup of antiretroviral therapy use have played a prominent role in this achievement. However, several issues remain to be addressed, 3 including the high diversity of circulating HIV strains and the limited availability of appropriate and advanced technology to determine HIV status of exceptional cases. 4 For example, in Cameroon, the HIV testing algorithm comprises Determine HIV 1/2 (Abbott Molecular Inc, Des Plaines, Illinois, United Sates), Hexagon HIV 1/2 (Human Biochemica, Wiesbaden, Germany), and OraQuick HIV 1/2 (OraSure Technologies Inc, Petchabun, Thailand). However, the weakness of the sample referral system, and the limited local availability of advanced technologies, among other reasons, continue to be a challenge in confirming the HIV status of some individuals in several African countries, including Cameroon. 5 Furthermore, poor adherence to the national guidelines of an HIV testing programme also significantly affects the consistency and reliability of HIV results. 6 This poor adherence might play a role in some individuals' denial of HIV results. 7,8 Thus, we present this case report to outline one of the challenges some individuals face in confirming their HIV status in Cameroon.

Ethical considerations
This diagnostic report was conducted per the Declaration of Helsinki principles and national regulations. The patient provided a signed informed consent, declaring his will to freely participate and authorising the usage of his medical laboratory findings in this report. No patient-identifying information was used throughout the paper.

Case presentation
We present the case of a 53-year-old married and asymptomatic man who received a confirmatory positive HIV diagnosis in 2016. The different tests performed, the methods used, and the corresponding time point are summarised in Figure 1.
After a consultation, he was determined to be HIV-positive following an HIV test request using rapid diagnostic tests: Determine HIV 1/2 (Abbott Molecular Inc, Des Plaines, Illinois, United Sates), Hexagon HIV 1/2 (Human Biochemica, Wiesbaden, Germany), and OraQuick (OraSure Technologies, Inc, Petchabun, Thailand); included in the Cameroon screening algorithm as per the World Health Organization HIV testing guidelines. However, his wife tested HIV-seronegative. Not convinced of his status, he †, The limit of the detection of the test is < 390 copies/mL; ‡, The limit of the detection of the test is < 20 copies/mL; §, The limit of the detection of the test is < 40 copies/mL. Blue boxes indicate the tests that have been performed in France. The texts in red indicate the positive reaction, while those in green indicate a negative reaction. ECLIA, electrochemiluminescence immunoassay; RT PCR, reverse transcription polymerase chain reaction; ELFA, enzyme-linked fluoresence assay; ELISA, enzyme-linked immunosorbent assay

Management and outcomes
So far, given that the patient remained asymptomatic with no evidence of viral replication, no antiretroviral therapy was initiated. We collected a new sample in our laboratory on 08 October 2021, and performed rapid testing according to the national algorithm, serotyping and HIV-1 viral load, but the outcome was serology-positive, viral load 'target-notdetected'. However, he was advised to avoid any HIV risk behaviour, and we continue to monitor his serological and virological status.

Discussion
Efforts have been made towards improving laboratory medicine in Africa, especially after the 2008 Maputo declarations. Some authors think a remarkable transformation has occurred in some areas of laboratory medicine, especially in those targeting the fight against HIV/AIDS in sub-Saharan Africa. 3,9 Nonetheless, numerous challenges, including weaknesses in the quality management systems, laboratory networks, human resources, and technological issues, must be appropriately addressed. 9,10,11,12 Despite testing progress, many factors influence the acceptance or refusal of provider-initiated testing and including self-trust, not being at risk for HIV, not being ready, and insufficient privacy and counselling. 8  We advocate that national public health laboratories should be equipped and strengthened to handle complex situations. Furthermore, besides the financial cost, there is the psycho-social burden posed on the patient due to an uncertain HIV status. The psycho-social burden goes beyond the individual level and affects the family and socio-economic dimensions.
There are still unresolved issues about the HIV status of this man. The antibodies are persistently reactive, serotyping is continuously indeterminate, and the viral load measurement is 'target-not-detected'. At this stage, the best way to demonstrate the presence of the virus would be to isolate it, but this will be challenging because of the undetectable viral load. It is still to be demonstrated, but we might also hypothesise that this man might be a rare case of an 'elite controller' or a 'long-term nonprogressor'.

Conclusion
Overall, this case highlights the struggles faced by some individuals in confirming their HIV status. In addition, it calls for the need to adapt existing technologies and develop an algorithm for managing special cases in low-and middleincome countries.